ESF-8 Malfunction: Follow the Money

The health and human services-related missions (Emergency Support Function [ESF] 8) are the most challenging for emergency managers because associated federal preparedness funding only reaches a few of the programs they need on game day. And that fiscal flow – in addition to the need for state-licensed professionals and private sector foundational challenges we've laid out in?NRF: Is ESF-8 Full of Holes?- keeps emergency managers and public health administrators on their heels during crises.

Yes, we are talking about the?Public Health Emergency Preparedness (PHEP) Cooperative Agreement?and the?Health Care Readiness and Response (HCRR) Cooperative Agreement (Formerly the Hospital Preparedness Program [HPP] Cooperative Agreement).

To understand how the administration of these programs is leaving ESF-8 full of holes, we must first understand how federal funding flows to the states and how it then gets divvied up – or in this case, doesn't get divvied up.

Fiscal Federalism

The?Tenth Amendment of the U.S. Constitution?states, "[t]he powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.

Neither emergency management, healthcare, public health, nor human services are delegated federal government authorities in the Constitution, which leaves them under the purview of the states. So, for the federal government to get what it wants, it "encourages" states to establish specific programs or carry out projects with financial enticements.?

These enticements are offered through congressionally authorized funding opportunities that, when accepted, are a contractual agreement between a state and the offering federal agency. These agreements are either grants or cooperative agreements. Academics call this funding for compliance dance fiscal federalism.

In the world of emergency management, there are many niche funding opportunities offered, but the so far reliable formula-based offerings available to all states are:

• Emergency Management Performance Grant (EMPG)
• State Homeland Security Program (SHSP) Grant
• Public Health Emergency Preparedness (PHEP) Cooperative Agreement
• Health Care Readiness and Response (HCRR) Cooperative Agreement (Formerly the Hospital Preparedness Program [HPP] Cooperative Agreement)

ESF-8 Funding: The State Disconnect

The?Federal Emergency Management Agency (FEMA)?maintains the?National Response Framework (NRF), including its annexes. Each annex has a coordinating agency and a primary agency, and in the case of ESF-8, the?U.S. Department of Health and Human Services (HHS)?is both. And that makes sense, as they are the agency created by Congress to manage all functions and activities related to health and human services for the federal government.

Given the breadth of HHS, one could argue that they are the Nation's ESF-8 Wizard. They are undoubtedly home to all the congressionally mandated healthcare and human services-related programs, including aging services and access and functional needs support services. I'm not saying they have staff to deliver these services directly, but they know what state agencies accepted the money and agreed to provide the programs on the ground.

You'd think knowing where health and human services funds go in each state would be simple. I mean, FEMA delivers its grants to state emergency management agencies, so shouldn't HHS send its funds to state health and human services departments?

No. Let's say it could be cleaner.

You see, another authority the Constitution did not delegate to the feds is the power to dictate how states structure their governments. As a result, each is unique, especially when it comes to health and human services. As such, it's the wild west when HHS programs hit the states, where few, if any, have an ESF-8 Wizard with the broad shoulders of HHS.

For example, let's use Illinois to illustrate the state split of HHS programs needed for the ESF-8 mission. To be clear, this is not a knock on Illinois. I've consulted in twenty states over the past decade, including Illinois, and have seen every combination one could imagine. None are wrong. But...

As you can see, following the money illustrates why ESF-8 is a hot mess. And the mess bleeds into ESF-6, where wrap-around support services for individuals in shelters and those sheltered in place must come from somewhere.

Part of the problem lies in the fact that directors of state agencies have much authority to operate their agencies as they see fit. And one of those independent decisions for public health directors relates to their propensity to want to keep their federal money home, even when rational comprehensive decision-making tells them otherwise. See Illinois.

Regarding the HCRR and PHEP cooperative agreements, there's an argument to be made that state public health departments should be financially supporting other ESF-8 agencies that are home to the authorities and resources necessary to deliver activities they've agreed to when accepting the cooperative agreement.

Do such interagency agreements happen? Unfortunately, I cannot testify to witnessing such.

Money Equals Deliverables

The problem with the state disconnect is not the money itself; it's the required activities accompanying it through the cooperative agreement. The principal investigator (PI) for the HCRR and PHEP cooperative agreements signs on the dotted line agreeing to perform all activities stated within. In all cases I know, that person is the public health department's preparedness director. And that person knows that their agency does not possess the expertise or resources to deliver what's required in the agreement.

But history shows they always sign and accept the money but do not support the preparedness efforts of the other ESF-8 agencies. Heck, if we're being honest, with few exceptions, most do not engage these critical partners whatsoever – until everyone is knee-deep in it.